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Canadian  Instituta  for  Historical  IMicroraproductiont  /  Inttitut  Canadian  da  microraproductions  historiquas 


r 


Technical  and  Bibliographic  Notes  /  Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best  original 
copy  available  for  filming.  Features  of  this  copy  which 
may  be  bibliographically  unique,  which  may  alter  any  of 
the  Images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming  are 
checked  below. 


El 
D 

D 

D 
D 

n 

D 

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n 


Coloured  covers  / 
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Covers  damaged  / 
Couverture  endommag^e 

Covers  restored  and/or  laminated  / 
Couverture  restaur^  et/ou  peiiicul^e 

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Cole  'ed  maps  /  Cartes  gdographiques  en  couleur 

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Only  edition  available  / 
Seule  Edition  disponible 

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interior  margin  /  La  reliure  serr^e  peut  causer  de 
I'ombre  ou  de  la  distorsion  le  long  de  la  marge 
int^rieure. 

Blank  leaves  added  during  restorations  may  appear 
within  the  text.  Whenever  possible,  these  have  been 
omitted  from  filming  /  Use  peut  que  certaines  pages 
blanches  ajout^es  lors  d'une  restauration 
apparaissent  dans  le  texte,  mais,  lorsque  cela  6tait 
possible,  ces  pages  n'ont  pas  6\6  film^es. 

Additional  comments  / 
Commentaires  suppl^mentaires: 


L'Institut  a  microfilm^  le  meilleur  exemplaire  qu'il  lul  a 
6\6  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire qui  sont  peut-6tre  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite. 
ou  qui  peuvent  exiger  une  modification  dans  la  m^tho- 
de  normale  de  filmage  sont  Indiqu^s  ci-dessous. 

[     I  Coloured  pages  /  Pages  de  couleur 

I I   Pages  damaged  /  Pages  endommag^es 


n 


Pages  restored  and/or  laminated  / 
Pages  restaur^s  et/ou  pellicul^es 


0  Pages  discoloured,  stained  or  foxed  / 
Pages  dteolor^s,  tachet^es  ou  piques 

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Showthrough  /  Transparence 

□  Quality  of  print  varies  / 
Oualit^  in^gale  de  I'impression 

'   i   '  .eludes  supplementary  material  / 
omprend  du  materiel  suppl^mentaire 

'■  Pages  wholly  or  partially  obscured  by  errata  slips, 
' —  tissues,  etc.,  have  been  refilmed  to  ensure  the  best 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuillet  d'errata,  une 
pelure,  etc.,  ont  6\6  film^es  k  nouveau  de  fa^on  k 
obtenir  la  meilleure  image  possible. 

I  I  Opposing  pages  with  varying  colouration  or 
' — '  discolourations  are  filmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'opposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
film^es  deux  fois  afin  d'obtenir  la  meilleure  image 
possible. 


This  (tern  is  filmed  at  the  reduction  ratio  checked  below  / 

Ce  document  est  tiimi  au  taux  de  reduction  indique  ci-dassoua. 


10x 


14x 


18x 


22x 


26x 


30x 


7 


12x 


16x 


20x 


24x 


28x 


32x 


Th«  copy  fitmtd  hare  has  b««n  raproducad  thanks 
to  tha  ganarosity  of: 

Special  Collections, 
D.B.  Weldon  Library, 
University  of  Western  Ontario 

Tha  imagas  appaaring  hara  ara  tha  bast  quality 
possibia  considaring  tha  condition  and  lagibility 
of  tha  original  copy  and  in  kaaping  with  tha 
filming  contract  spacificationa. 


Original  copias  in  printad  papar  covara  ara  fllmad 
baginning  with  tha  front  covar  and  anding  on 
tha  last  paga  with  a  printad  or  illustratad  impras- 
sion,  or  tha  back  covar  whan  appropriata.  All 
othar  original  copiaa  ara  filmad  baginning  on  tha 
first  paga  with  a  printad  or  illustratad  impraa- 
sion.  and  anding  on  tha  last  paga  with  a  printad 
or  illustratad  impraasion. 


Tha  last  racordad  frama  on  aach  microficha 
shall  contain  tha  symbol  — ^  (maaning  "CON- 
TINUED"), or  tha  symbol  V  (maaning  "END"), 
whichavar  applias. 

Maps,  platas.  charts,  ate.  may  ba  filmad  at 
diffarant  raduction  ratios.  Thosa  too  larga  to  ba 
antiraly  includad  in  ona  axposura  ara  filmad 
baginning  in  tha  uppar  laft  hand  cornar,  laft  to 
right  and  top  to  bottom,  as  many  framas  as 
raquirad.  Tha  following  diagrams  illustrata  tha 
mathod: 


L'axamplaira  filmA  fut  raproduit  grica  i  la 
g4n4rositA  da: 

Speclal  Collections, 
D.B.  Mel don  Library, 
University  of  Western  Ontario 

Las  imagas  suivantas  ont  iti  raproduites  avac  la 
plus  grand  soin.  compta  tanu  da  la  condition  at 
da  la  nattat*  da  l'axamplaira  film*,  at  an 
conformity  avac  las  conditions  du  contrat  da 
filmaga. 

Las  axamplairas  originaux  dont  la  couvartura  an 
papiar  ast  imprtmAa  sont  filmAs  an  commanpant 
par  la  pramiar  plat  at  an  tarminant  soit  par  la 
darniira  paga  qui  comporta  una  amprainta 
d'imprassion  ou  d'illustration,  soit  par  la  second 
plat,  salon  la  caa.  Tous  las  autras  axamplairas 
originaux  sont  filmis  an  commanpant  par  la 
pramiira  paga  qui  comporta  una  amprainta 
d'impraasion  ou  d'illustration  at  an  tarminant  par 
la  darni4ra  paga  qui  comporta  una  talta 
amprainta. 

Un  daa  symbolas  suivants  apparaitra  sur  la 
darniira  imaga  da  chaqua  microficha.  salon  la 
cas:  la  symbols  ^^  signifia  "A  SUIVRE ',  la 
symbola  V  signifia  "FIN". 

Las  cartas,  planchas,  tableaux,  ate.  peuvant  fttra 
filmAs  A  das  taux  da  reduction  diff^krents. 
Lorsqua  la  documant  ast  trop  grand  pour  iu» 
raproduit  an  un  saul  clichi,  il  ast  filmi  i  partir 
da  I'angla  supAriaur  gauche,  da  gauche  it  droits. 
at  da  haut  an  bas,  an  pranant  la  nombra 
d'imagas  n^cassaira.  Las  diagrammas  'uiva.-its 
illustrant  la  mAthoda. 


1  2  3 


1 

2 

3 

4 

(II 

6 

4 


An  Extra-Abdominal  Multilocular 
Ovarian  Cyst 


THOMAS     S.     Cirr.  LKN.     M.D. 

BALTIMOKE 


Keprinted  frm  The  Journal  of  the  American  Medicat  Attoctation 
Oct.  14.  »»,  Vol.  LVIl,  pp.  asi-tiis 


COPIRIOHT,  1011 

AMKHirAN    MEHIl'Al.    AaS(>CIATH>N 

KlVK    IlrMIBKI)  AND   Til  IIITV-KIVE    IIEARBOIIX    AVENUE 

J'HirAGO 


.VN  EXTRA-ABDOMINAL  MULTILOCULAR 
OVARIAN  CYST* 


TIIOAIAS  8.  CULLEN,  M.D. 

DALTIMOIE 


Several  niontlir*  ago,  Dr.  Frank  R.  Smith  asked  me 
to  see  a  woman  who  had  a  kidney-shaped  tumor  slightly 
below  and  to  tlio  right  of  the  umbilicus.  The  patient 
had  noticed  a  small  lump  in  this  situation  several  years 
before,  which  for  a  long  while  had  remained  nuiescent 
but  during  the  last  year  had  gradually  increased  in  size. 
At  operation  it  was  found  to  be  a  partly  solid,  partly 
cystic  tumor  of  the  ovary  lying  external  to  the  abdom- 
inal mustles,  the  tumor  and  its  surrounding  sac  being 
covered  over  with  a  small  amount  of  adipose  tissue  and 
the  skin.  The  pedicle  of  the  tumor  passed  through  a 
hernial  ring  to  the  outer  side  of  the  right  rectus  and 
obliquely  across  the  lower  abdominal  cavity  to  what 
corresponded  to  the  normal  insertion  of  the  right  utero- 
ovarian  ligament. 

I  have  been  unable  to  find  any  reference  to  a  similar 
case  in  the  literature. 

History.— yit».  M.  W.,  aged  56,  was  a  short,  well  developed 
woman,  and.  apart  from  a  tumor  mass  in  the  lower  abdomen, 
wa»  in  excellent  health.  She  had  had  eleven  children.  Her 
periods  had  ceased  at  50.  She  had  felt  some  pain  in  the 
right  ovarian  region  for  fifteen  years,  and  for  about  ten  years 
she  had  noticed  a  little  tumor  situated  in  the  right  lateral 
ab<lominal  wall  slightly  above  a  line  drawn  between  the  umbili- 
cus and  the  anterior  superior  spine.  This,  from  her  descrip- 
tion, seemed  to  have  been  about  the  size  of  an  ovary.  During 
the  last  ten  months  this  small  lump  had  increased  in  size 
until  it  formed  a  lobulated  mass,  elongate  in  form,  about  10 
by  8  cm.  It  seemed  to  be  but  a  short  distance  beneath  the 
skin  and  could  be  lifted  up  to  some  extent  in  the  hand,  but  its 
absolute  relationship  could  not  be  determined  on  account  of 
the  presence  of  a  considerable  amount  of  adipose  tissue. 

*  From  the  Gynecologicul  Ucpartmtnt  oi  the  Johns  Ilnpklns  Hon- 
pltal. 


Opiiiilion. — Nov.  I,  11)10,  on  ninklnii  u  pelvic  exiiminntinn, 
iimli'r  iinpittlii><-iii  I  (imiikI  that  flip  iitt-riiit  whh  noriiml  iiiiil  tlmt 
there  wiiH  no  thirkmiii';  hitt>r«ll,v.  Not  being  KUre  of  the  exact 
I'onilition,  I  tiiadt-  a  nifiliaii  Inciiiinii.  Th<*  iiterii*  wan  iiorinal. 
thi-  left  tuU-  ami  ovary  prt-nenteil  the  iixiial  Mp|M>aranci'.  The 
rifiht  lulie  Khdweil  no  i-haiif((>.  Iiiit  the  right  utern-ovarlan  liga- 
ment wan  niarkiHlly  dra  -n  out  into  a  Uind  nlmut  I  cm.  bruad. 
ThU  Inl  to  a  hernial  o|>ening  with  Hmooth  margimi  in  the  right 
lateral  aUlomlnal  wall  In-Iow  and  to  the  riglit  of  the  uii>biliciiii. 
but  at  leaHt  I'i  rm.  from  the  inguliMl  region  I  Kig.  1).  After 
obtaining  giHxl  e.\|M>iiure  I  found  that  thin  tiattenetl  band  of 
the  utiro-ovarian  ligament  pa»>ie<l  directly  into  a  hernial  open- 
ing aUint  2.5  em.  in  diameter,  and  into  thi*  opening  a  Hnger 
could  readily  In-  introtluoHl.  The  intra-aUlominal  |Mirtion  of 
the  |HHlicle  wnH  elani|H-d  olT  and  autured.  An  ineiHion  wax  then 
made  over  the  prominent  part  of  the  alMlominal  tumor,  which 
prove<l  to  lie  extrn-alxlominal.  The  more  prominent  part  of 
thin  tumor  lay  directly  lN>neath  the  xkin  in  the  adipoae  tiHnue, 
and  waf*  very  eaHily  fretnl  by  blunt  dii4Nertion  to  the  |ioint 
where  tin-  hernial  ring  entered  the  abtlonKii.  I  then  cut  the 
peritoneum  around  the  hernial  ring  and  delivered  the  tumor, 
with  itH  |>eritoncel  covering  intact.  The  Kjiaie  where  the  tumor 
had  existe<l  having  lieen  obliterated  and  the  inner  ineiHion 
Iiaving  Ix-en  ituture<l.  the  outer  wound  wa»  aUo  cloned.  The 
ovar'  Ml  tumor  wax  nuiltilocular. 

Tlu're  had  evidently  N'en  a  hernial  protrunion  through  the 
right  lateral  abdominal  wall,  into  which  the  ovary  had  droppe<l 
and  remaine<1  for  several  year*.  During  the  hiHt  ,vear  it  had 
increa^Ml  in  itize  and  given  rine  to  a.  multiliKMilar  ovarian  eynt. 
Xaturally  w-ith  the  increaite  In  iiize,  the  e»ea|i»'  of  the  ovary 
from  the  rnic  \va»  im|HisHible. 

UnrroKropir  Krnntinnlion  of  Hardriinl  Nprriinrn  (Path.  Xo. 
I.').72.'<). — The  hernial  opening  was  alxnit  i.'i  em.  in  diameter 
ItH  margins  consisted  of  peritoneum,  outside  of  which  was  a 
/.one  of  adi|Hise  tissue.  The  tumor  itself  was  kidne,v-shaped 
(  Kig.  2)  12  cm.  hmg.  7  cm.  broad,  and  t)  cm.  in  thickness.  It 
..as  e<ivercil  eveiywhere  with  |>eritoneum.  wliicli  could  lie  read- 
il.v  separated  from  it.  Here  and  there  attached  to  the  outer 
surface  of  the  peritoneum  were  tags  of  adipose  tissue.  The 
tumor  itself  was  in  large  measure  solid,  resembling  a  fibroma. 
It  pre^iented  a  lobulated  ap|>earttnce.  Here  and  there  lietwecn 
niHlules  it  showed  cystic  spaces,  ubiong.  irregular,  or  round, 
varying  froiu  2  mm.  to  2  cm.  in  diameter.  The  majority  of 
tliese  were  transparent  an-l  contained  clear  tluid.  Some  of 
tlieni  were  slightly  bloisl-tinged.  So  much  could  he  made  out 
througii  a  window,  which  was  cut  in  the  peritoneum.  On 
peeping  in  tlirougli  the  hernial  ring,  were  seen  cysts  varying 
from  2..'>  cm.  to  I!  cm.  in  diameter  and  apparently  fllleil  with 
clear  fluid.  Al'ler  the  <lrawin<'  had  lieen  made  the  tumor  was 
cut  in  two.  The  apjienrance  on  section  is  well  shown  in  the 
dniwing  in  the  rigid   upper  corner  of  Figure  2. 


m»loioific  KxaminnliuH. — Tlir  *olitl  |Mirtion  <>(  the  tumor 
connUti-il  In  larifc  purt  uf  lllirouo  tUiiuv  mntHininR  triangular 
or  apinilltfuliaiHil  nut'lt^i.  In  iMinit'  plart'*  the  nurlfi  wrrc  abun- 
dant, in  othprx  scanty  In  niinilirr.  The  tiriiiu(>  RlioMml  a  vim- 
aiilcrnble  tjpgrec  <>(  hyaline  .li,ienrration.  At  unp  or  Ivto  |M)intii 
rliarai'lrriiilii-  ovHriaii  atrnnM  wm>  xtill  in  t>vi(|>-nre.  No 
Graallan  fullicle^  toulil  be  founti,  but  after  an  examination  of 
numerouK  •••H-tionn  a  typical  cKrpi.s  flbrtwiim  wb«  noted.  In 
w)nie  Dt'i'ticin*  a  few  hundUn  of  ii.y  «lri|>e<l  munrle  were  viiible. 
'Ilie  stroma  had  a  ni(>ii|;vr  bl<MHl-«up|>ly  except  in  a  few  aieas, 
where  there  were  |iruu|>-<  of  rather  large  veins. 

Sraltercd  »|>nrini(ly  through  the  stroma  were  small  circular 
or  irregular  glandt  iiecurring  singly  or  in  groups  i  f  two  or 
three.  They  were  found  to  be  line<l  with  ryiindrical  epithelium 
and  were  similar  lo  those  so  fre<|uently  noted  in  the  biluin 
of  the  "nry.  Some  of  the  very  small  cystic  spaces,  noted 
ninrrnseo|ii'  .lly,  were  line<l  with  cylindrical  ciliatt.l  epithelium 
and  had  an  underlying  stroma  that  itained  rather  deeply  and 
that  ronsisted  of  cells  with  oval  vesicular  nuclei.  Tl.ib  ttroma 
stood  out  in  sharp  cimtrast  to  the  surrounding  tlbrou*  tissue. 
Such  cysts  frei|uently  rontainetl  a  little  fairly  freah  blood. 
These  cysta  reminded  one  very  much  of  the  cystic  spaces  so 
frei|iiently  noted  in  an  adenomyoma.  but  I  btdieve  that  they 
represented  only  the  earlier  stages  of  the  larger  eysta. 

The  large  cysts  were  lined  with  one  layer  of  epithelium 
which  might  be  cylindrical,  cuboidal  or  almost  flat.  Projecting 
into  sf.me  of  the  cysts  were  papillary  folds.  These  occasionally 
occurred  as  delicate,  irregular,  finger-like  projections,  but  in 
the  main  as  blunt,  single  or  branching  outgrowths.  All  of 
them  were  covered  over  with  one  layer  of  epithelium.  The 
stroma  uf  the  papillary  masses  had  in  many  places  undergone 
almost  complete  hyaline  degen<>ration,  and  in  e  few  liquefac- 
tion of  this  hyaline  material  had  taken  place.  Even  in  some 
of  the  larger  cysts  a  moderate  amount  of  fresh  blood  was 
present.  The  stroma  cells  beneath  the  cyst  epithelium  had  in 
some  places  become  swollen  and  spherical  and  were  filled  with 
yellow  or  brown  ]>igment  indicating  the  absorption  <>f  blood 
lit  tome  previous  time. 

On  the  surface  of  the  tumor  were  ii  moderate  number  ■  >h8- 
culai  .idhesions,  and  on  the  under  and  protected  side  (<  these 
the  peritoneal  cells  had  become  cuboidal  aa  i  :'omni'>  in  the 
under  side  of  tubal  or  ovarian  adhesions. 

From  the  above  description  it  will  be  seen  that  the  dense 
matrix  of  the  tumor  consisted  essentially  of  fibrous  tissue  and 
that  scattered  throughout  this  were  multiple  cysts,  in  large 
measure  similar  in  character,  some  of  which  had  small  papil- 
lary masses  projecting  into  them.  Had  the  tumor  developed  in 
the  abdominal  cavity,  I  believe  that  in  all  probability  it  would 
have  bei-n  a  multilocular  cystomo.  but  as  it  lay  between  the 
abdominal  muscles  and  skin  a  rapid  cystic  growth  was  much 


more  ilitlhiilt,  uikI  Hi.-  Ill>r<iii>  ti*«iie  wh»  lhii«  allowml  In  ki^p 
|>nif  with  till-  i-y»lii'  fiirniHtioii. 
'I'liiTP  HHK  ii<i  »i|(ii  iif  niitliKnnnr.\ . 

THK   I-IIKMKXIK  Of  (IVVIIIKM    IS    IIKH\HI,  H  l(  H 

Till'  (Krurrciiie  of  oMirics  hiuI  nviirian  tiiinoni  in  her- 
nin!  fm-*  in  of  |>nr»itiilur  intircxt  in  tliix  (oniiwtioii.  I 
shall.  llnTt'forf.  l)ri»'Hy  tlimiiM  tlit-  iiion-  iin|Nirtaiit  ton- 
triltutiono  nmdi'  in  tliJK  fifid. 


.    Ilitv!  "..■*"'■*"    '  *:0"LE  rAHHINO    KROJI    fTEBlH,    OUT  TllHOfdll 

H.  n  ,?f  ft''  '"i"!  '^■'"i■  -^""'"'XA'-  Wall.  A  xohemntlc  repri-nentn- 
tlyn  of  thp  pplTlo  »lru<tiir.«  iih  found  at  owrellon.  The  uterus  uiil 
.'ft  app.nilaK,.«  wore  normal.  The  right  tube  w««  unaltered,  but  patii- 
..^i"^?"  ""■- "««"™»  "^.•"ff  H"-  f'stht  ovary  .hould  have  been  wM  a 
th?„..  h  .  ■.i!?'"'-.  T*","  '""  "'Pw*''''  nna  outward  and  paased  out 
through  an  abdominal  ring  to  the  outer  Hide  of  the  right  rettua  At 
tbo  ring  a  finger  could  b.>  imaned  tompletely  around  this  pedicle.  It 
r„Hi  ?,""'?.,''''*  '"''IT'",'"  "'»  ring.  A  glance  at  the  umblllcua  will 
Indicate  the  exact  lo<atlon  of  the  ring.  On  looking  thronsh  the  ring 
a  jmall  portion  of  the  glUtenlng  tumor  could  be  Teadlly  seen  The 
dotted  line  Indicates  the  relative  size  of  the  tumor 


The  ovary  liiiit  a  ratlirr  ho  ixcurMiiK,  hihI  it  i^  not 
to  Im!  wonilcriMl  Ht  tlint  hIicii>  nn  iti^^iiiaal  or  feinurnl 
hernia  vxittt*  tlir  uuiry  nml  ntten  the  tiil>«  form  part 
of  tlR>  conti'ntH  of  tlif  iif!  nml  .«iir.  I'liwh'  m  1H7!I  i  nn- 
trihutctl  a  in<i«t  interts  ii^  nrticlf  nn  lurnia  of  the 
ovary.  In  aihlition  to  hiM  owi<  iiim^K,  lie  ri>fi>ni  to  tlwuic 
of  Pott.  I^iitNUi),  IhMicux,  (tiu'ruant.  I'arkcr,  Brun  ,  War- 
ren, MeadowM,  Cukco,  t'oote,  Knulinrh,  Weinjechner, 
MacCliicr,  Monni'nburjr,  Worth  anil  Hlu'indtaedter.  In 
brief  his  pajM'r  »ayn  that  the  ovary  may  pass  out  at  any 
of  th<'  natural  aiNlominal  opi>nin>;i«,  ami  that,  when  it 
doe»  HO,  it  i*  niont  fre(|Ui'ntly  l>y  way  of  tin-  femoral  or 
in|;uinal  nn^i.  The  in;ruinal  hernia,  whieh  in  the  more 
fre<|uent,  may  U-  eonftenital  or  accidental.     The  con- 

'Mo;    inalof;ou8  to 


y-eij{ht  eases  of 
iir  were  inoontcst- 
and  seventeen  acci- 
werc    unilateral    in 


genital  hernia  is  produced  by 
the  descent  of  the  testicle, 
hernia  containing  the  ovary, 
ably  congenital,  seventeen  dou!.  . 
dental.  The  'ongenital  hernias 
twenty-seven  cases,  bilateral  in  twenty-seven  cases  In 
the  unilateral  cases  the  left  side  was  more  frequently 
involved.  In  cases  of  double  hernia  the  presence  of 
the  ovaries  in  the  hernial  sac  was  sometimes  associated 
with  defective  development  of  the  generative  organs. 
Puech  ha«l  records  of  sixteen  cases  in  which  the  ovary 
was  contained  in  a  femoral  hernia.  In  eleven  of  these 
cases  the  hernia  v*as  on  the  right  side  and  in  four  on 
the  l.'ft. 

The  uterus  or  one  of  its  corrua  was  found  ten  times 
in  the  sac  in  cases  of  inguinal  hiTuias,  three  times  among 
the  femoral  hernias. 

Dr.  Jof  ^h  C.  Bloodgood  tells  me  that  he  has  had 
two  caseF  'emoral  hernia  with  the  o\ary  lying  in  the 
hernial  sa. 

rJevo'-al  tears  ago  I  operated  on  a  child  in  Cambridge 
fi-i-  an  inguinal  hernia.  The  sac  contained  the  right 
t:'  p  and  ovary.  They  were  so  intimately  blended  with 
th  '^.iC  that  it  was  impossible  to  save  them,  and  they 
were  removed  preparatory  to  doing  a  radical  operation.' 

1.  Puech,  A. :  Nourellci  rechercb'^  lur  loi  bcrnlei  de  l'oTalr«, 
Ana.  de  gjnfc.,  Fkrii,  1870,  xl,  401. 

2.  Thl(  niie  wai  reported  and  lllnitrated  lo  an  article  pabUshed 
by  Dr.  Prank  T.  Andrewa  (Hernia  of  tbe  OTary  and  Tube,  The 
JorBNAL  A.  M.  A..  Nov.  24.  1908.  p.  1707).  Dr.  Aodrewi'  article 
kIti's  nn  I'xcellent  r^aumf  of  hernia  of  the  ovary  and  tube,  und  Ilkc- 
wUe  contatna  a  long  tabulation  of  caiei  heretofore  obserred. 


(i 

My  exp,Ti,.nce  with  ovaries  in  l.erni.il  rinps  associ- 
.;.    w.  i,    aok  of  .levolopmont  of  the  crener.tive  organs 
m>  heeu  limited  to  one  fase.'' 

A  posti.|x.rativc  hernia  occasionally  contains  an  ovarv 

'ke'CV^  /'/'r;  "l  *''■'  ^•'""•..-ter- several  years  apo> 
I  he  patient  iia.l  had  an  appendix  ahscess.  whicli  it  had 
.en  necessary  to  drain  liberally.  The  resultant  hernia 
in  the  scar  was  very  tender  and  in  .lissectin?  it  out  1 
fonn.l  hat  the  sensitiveness  was  due  t..  the  presence  of 
the  right  ovary  contained  in  and  adherent  to  the  hernial 

OV.VKIAX   Tl-MOllS   WAKUmyG   IX   THE   INGCINAL  CANAL 

Since  one  or  hotli  ovaries  may  occasionallv  be  found 

•"  tbe  ugmnai  canal,  we  shonhl  not  be  surprised  to  find 

';•«■  "...    then  a  case  in  which  such  an  ovary  under.-^s 

..nor  development.     ISheinstaedtei-   in   187«   repoS 

t  1  f  !  '■  '"  *'"'  "e.ghl,orhoo.l  of  the  clitoris  In 
addition,  here  was  a  riglit-sided  globular  mass,  which 
w.>  tound  to  be  a  right  inguinal  hernia.  The  ova 
""".'.•^vas  larger  than  a  chil.rs  head.  ela.stic  and  appiJ 
v  «..<■  tiiant.  The  overlying  skin  was  normal 
""I'able  diagnosis  of  ovarian  tumor  in  a  left  in-uinal 
H'  'ma  was  made.  Six  months  later  the  left  hernh,  si^ 
«as  opened.    The  tumor  was  easily  rni.od  and  its    roa^  - 

nicnt  wa.  tied  off,  some  adherent  loops  of  small  bowel 

v'umWW   "t.'"':'"'  "P  '"*°  the 'abdomen,  ind  ?h 
fl.'iHKl  Closed.      I  he  tumor  weighed   7-50  a,,,      Careful 
examination  of  the  right  hernia  revealed^  I  e  pr  S 
01  the  ovarv  in  the  sac.  '   >-t:uie 

di^Inoil"fi!;  r''"  "'''''^'  ^^'^  .i.ie.-o.^opic  examination, 
diagnosed  the  tumor  as  an  angiosarcoma. 

ierl   wn'^nM    7'i"r'r'"^  ♦'"^'  ''■^""ture  on  the  sub- 
ject. «as  able  to  find  only  one  case  in  which  an  ovarian 

I  >   i^eigel.     i  he  hernial  sac  contained  a  portion  of  an 
;>variancy.st,theremamderof    which  lay  in  the  pelvi" 

canals.  S„rg.  Ci.vnoc.  and  Obst.    Jul"  '  1910    n   tT     ""  *""  ""^""" 
Fol/o«.  n«  Ta  'op1?aUon-J''A?^ii:S.°"i   ■'"'•'''•  -Abdominal  Soar 

o.n4"l!ilL?|J.rr?/4Vce?,'^1K«S^^^^^^^^^  Ovarii     ,n 


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8 


Of  solid  ovarian  tumors  i-ontiiineil  in  hernias  he  men- 
tions only  a  case  of  Guersant  reported  by  Englisch. 

Fargas,*  in  1890,  described  the  case  of  a  woman,  aged 
38,  who  had  a  tumor  the  size  of  a  man's  head  occupying 
the  right  inguinal  and  labial  region.  On  the  left  side 
was  an  inguinal  hernia  containing  an  ovary,  which  was 
easily  reducible.  The  patient  said  that  until  eight  years 
previous  the  right  side  had  presented  the  same  appear- 
ance as  the  left,  and  Fargas.  therefore,  diagnosed  the 
tumor  as  a  right-sided  ovarian  cyst.  Six  years  prior  to 
observation  the  right  hernia  had  become  irreducible,  and 
after  that  had  gradually  increased  in  size. 

The  hernial  sac  was  opened  and  the  cyst  lay  free  from 
adhesions.  Its  pedicle  was  tied  off  as  in  an  ordinary 
ovariotomv  and  the  tumor  removed.  The  patient  made 
a  good  recovery.  The  cyst  was  reticulated  (multilocu- 
.lar).  Fargas  "confessed  that  it  might  have  been  con- 
founded with  a  cyst  of  the  round  ligament,  but  its  topog- 
raphy rendered  its  source  certain.  The  woman  had  had 
noniial  menstruation  and  had  borne  two  children  dur- 
ing the  existence  of  this  tumor. 

Seymour'  in  18!»;  reported  the  case  of  a  woman  aged 
48.  Two  years  before  coming  under  observation  a  small 
tumor  ha(i  appeared  in  the  right  groin.  It  was  some- 
what sensitive,  hard  and  irreducible.  An  inguinal  her- 
nia with  possibly  an  incarcerated  omentum  without 
strangulation  was"  thought  of.  At  operation  the  tumor 
was  found  attached  to  the  uterus  by  a  pedicle,  4  inches 
long  and  %  inch  in  diameter.  This  passed  out  through 
the  inguinal  ring  to  the  under  surface  of  the  upper  end 
of  the  tumor  in  the  inguinal  canal.  The  pedicle  was 
tied  off  and  the  sac  closed.  The  tumor  was  ovoid  in 
shape,  4  inches  in  length  and  S  inches  in  circumference. 
The  microscopic  report  was  spindle-celled  sarcoma.' 

(t  Karsas :  Xotp  sitr  un  ons  dp  liernle  Ingulno-lablale  dp  Vovoire 
driiit  uvpc  (?r»8  kystp  rStlculairo  du  mSnie  organp,  Arch,  do  tocol., 
I'arls,  1800,  xvil,  T67. 

7  Spymour:  llornla  of  a  Sarcomatous  Ovary,  Tr.  Med.  Soc. 
StalP  of  N.  Y..  18!)7,  p.  370. 

8  If  the  fibrous  character  of  a  solid  ovarian  tumor  U  definite, 
one  Is  safe  In  making  a  diagnosis  of  fibroma,  and  If  the  growth  con- 
sists of  spindle  cells  and  has  many  mitotic  figures  and  atypical  cell 
changes,  one  can  with  Justice  make  a  diagnosis  of  sarcoma.  There 
are  however,  quite  a  number  of  solid  tumors  of  the  ovary  of  the 
snlndle-cellpd  type.  In  which  It  Is  Impossible  to  say  from  the  micro- 
scoDlc  examination  whether  the  growth  Is  a  sarcoma  or  a  fibroma. 
In  su.h  cases  the  ulagnosls  can  npvpr  be  definitely  determined  unless 
the  patient  subsequently  develops  metastases. 


I) 


AX   OVAllIAX  CYST  IMIOTIUDlXd   1"''0  THE  INOUINAL 
GAKAL 

BaUly"  in  1S98  roportod  an  interesting  case  of  this 
charatt'er.  Two  voars  Iwfore  coming  under  Baldy's 
observation  the  patient  had  noticed  a  small  peduncu- 
lated tumor  in  the  right  inguinal  region.  This  had  con- 
tinued to  grow  until  it  was  as  large  as  an  egg  and  had 
then  been  removed.  A  year  later  a  larger  and  similar 
growth  had  been  present  and  had  also  been  removed. 


KlK.  ."t.— An  Extra-Abimimisai,  Mixtilocular  FibbOCISTOMA.  A 
schemntlo  ropreHentatlon  <>(  thf  mannt-r  In  which  the  tumor  tended 
to  develop  when  relieved  from  Its  surrounding  pressure.  It  In 
reality  ronslsted  of  four  lob«'»  similar  In  character  and  Jolneil 
together  by  broad  or  narrow  pedicles. 

When  Baldy  saw  the  patient  the  growth  was  as  large  as 
a  list.  A  pelvic  examination  revealed  a  mass  filling  the 
right  side  of  the  pelvis. 

At  operation,  an  incision  was  made  directly  over  the 
growth  and  the  tumor  freed  down  to  a  thick,  broad. 

0    Baldy,  J.  M. :    Ovarian  Cyst  Protruding  Through  the  Inguinal 
Canal,  Am.  Jour.  Obst.,  1808,  xxxvlll,  827. 


10 


sliort  pi'diik'  wliicli  ]mss('il  into  iind  tliroiijili  tlie  injjuiiml 
iiiniil.  'J'lic  attiicliniL'iits  of  the  pi'diclo  in  tho  cnnnl  were 
fiTfd  and  tlie  (iiijicr  forced  into  the  ahdonion  wIrmi  it 
was  found  that  tiic  timior  was  a  continuation  of  a  hir^e 
intra-alxloniii'.al  Tna--. 

When  tho  aUdomi'ti  was  (ipciicd  in  tho  nit'dian  line, 
the  iK'diclo  of  tlio  injruiual  ;;i'o\vth  was  found  sprinjrinj; 
from  a  htrfic  intrali-ianiontarv  tumor  simihir  in  diarac- 
tor.  The  U'ft  uterine  a]>penih»';es  wore  normal.  A 
supra\a;:inal  hvstere;tomv  was  iH'rfornied  aiul  the  her- 
nial rini;  closed.  'I'he  patient  nuido  in  uninterrupted 
recovery. 

AX  OVAlilAX  CYST   I.YrN.J    I'AliTI Al.I.V    l\   A    nCMdlfVL 

i[i;i(NiA 

This  condition  is  exceptionally  rare.  |)(>llhaes"'  in 
ISS.")  cited  the  ease  of  a  woman,  a;:od  •")•■>.  who  entered 
the  hos]iital  in  1ST!)  on  account  of  ascites.  For  four 
years  she  had  conii>lain<'(l  of  discomfort  in  tho  lower 
alidomen.  and  there  had  lieen  an  increase  in  size  in  the 
ri,;.'ht  side.  Thereafter  she  had  had  a  crural  hernia  on 
the  riirht  sid<'  and  for  the  last  nine  months  a  similar 
hernia  on  the  left.  The  riuht  was  rediicilde,  the  left 
irreduciiile. 

After  tho  patient  liad  heen  huilt  u]t  to  some  extent 
and  after  tho  ascitic  fluid  had  heen  removed  several 
times  by  puncture,  a  riszht-sided  ovarian  tumor,  partly 
solid,  jiartly  cystic.,  was  removed. 

The  left  ovary  was  cystic  and  enlarjjed.  It  was  partly 
situated  in  the  pelvis  and  had  to  ho  separated  from  a 
sidid  cord  which  jiassed  into  the  femoral  cnnal.  The 
major  portion  of  the  larfre  cystic  loft  ovary  lay  in  tho 
fold  of  tho  proin  and  fourteen  day.  later  was  removed 
throi.^rh  a  herniotomy  incision.  This  portion  was  as 
larc:e  as  a  child's  head.  The  ])atient  made  a  complete 
recovery. 

A   SMAl.I.    POKTION    OF    .VX    OVARI.VX    CYST    IXCAItCEliATKD 
IX  Tin:  AHHOXIIXAI.  WAI.I.  .11  ST  HKI.OW  TIIK  fMHlI.IClS 

Hopkins"  in  1S!I4  re])ortod  an  intorestinj;  cmerirency 
case.  The  patient,  ajred  'u,  was  admitted  for  a  sup- 
l)oscd  stran>:ulated  nmhilical  hernia.     Protrudinfr  just 

10.  DfUhaos :  F.  no  Ilt'rnln  cniralls  evstovarll  stnlDtrl,  Ztsilir. 
f.  Gpbnrlsh.  ii.  Gynak..  18S.'>.  xi.  .fSft. 

11.  ll<ipklns.  Gporgi'  G.  :  An  Ovarian  Cyst  Simulatlne  !i  Str.Tn>!ii- 
latcd  I'mhiilinl  lli'rnla..  lioston  Mod.  and  iSurg.  Join..  .Inly  L'li, 
1S04.  p.  .H4. 


11 

below  the  umliiliciil  oiK'nini:  was  en  almost  black  tumor 
die  size  of  a  walnut.  Still  thinkinjj  that  it  was  a  stran- 
gulated hernia,  the  niK>rator  tut  the  eonstricting  band 
and  the  tumor  at  "nee  disappeared.  The  abdominal 
openinf:  was  enlarged  anil  serous  and  jielatinous  mate- 
rii'l  ix'gan  t"  pour  out.  On  further  exploration  a  mul- 
tilocu'iir  ovarian  lyst,  weifrhinjr  about  'i't  jiounds,  was 
found,  'iiiis  was  removed  and  the  patient  promptly 
recovered. 

A  small  pDition  of  this  cyst  had  become  strangulated 
in  a  small  hernial  defect  just  below  the  und)ilicu8. 


nKFFC'JS    IN'   TllK   AHDOMIN.VI.    WAI.l. 

.V  study  of  the  weak  spots  ;  the  abdominal  wall  is 
of  interest.  Levadoux'-  in.ule  a  most  exhaustive  exam- 
ination of  the  inner  api>earaiu-c  of  the  umbilicus,  of  the 
final  disposition  of  Uie  um'  -ai  arteries,  the  umbilical 
vein  and  the  unuiius,  and  ilcscribed  in  detail  how  tl.t^se 
sometimes  blended  in  such  a  manner  as  to  form  a  fibrous 
sheath  that  completely  covered  over  the  inner  umbilical 
opening.  In  the  course  of  his  studies  he  also  noted 
weak  spots  in  the  fascia  just  beneath  tlu  ]H'ritoncuiii. 
These  openings  were  usually  small  and  were  oval,  round 
or  ir"eguiar  in  shajH". 

On  i-areful  scrutiny  it  has  at  times  been  noted  that 
hernias,  su|)posed  to  be  umbilical,  were  in  reality  ]ieri- 
umhilical  and  that  tfie  umbilicus  itself  was  intact. 
These  defects  in  the  fascia  are  undoubtedly  the  cause  of 
such  hernias.  In  July,  1!U0,  I  saw.  in  consultation 
with  Dr.  A.  II.  A.  Maye..  a  boy,  aged  IT,  who  had  a 
small  hernial  protrusion  4  cm.  above  and  to  the  left  of 
the  umbilicus.  This  hernial  |  rotrusion  projected  1  cm. 
through  the  fascia  and  was  lohulated,  forming  a  mass 
;{  cm.  in  diameter.  The  patient  was  of  spare  build.  On 
cuttinsr  down  on  the  hernial  sac  I  found  a  small  defect 
in  the  abdominal  wall  with  a  small  portion  of  the  oinen- 
uni  i)rniecting  through  it.  The  omentum  was  readily 
retu'-ned  and  the  oitening  easily  obliterated  with  a  few 
sutures. 

Dr.  Bloodgood  tells  me  that  he  ob=ervjd  a  case  of 
liernia  of  the  abdominal  wall  at  the  s  inar  line,  that 
was  between  the  rectus  niuscle  and  j  forming  the 


12.  I.ovadoux,  ^nclll'l-.^n»^•^lll  :  Vi>ili'tt''s  ilp  I'limblUo  <>t  <li"  »<"s 
nnncxps,  Thf-xo  Kac.  <U'  Mrd.  et  (I  I'harin.  rte  Touloiiw.  1007.  Xo. 
711. 


IiiIi'imI   Ml><li>ii]iiiiil    umI 
flit    lodlis   of   siiiill' 


Tl 

■I.    r 


ic  -ill    ( iiiitiiiiu'il  noii-iiillii'r- 
niiditioii  was  romlilv 


III  our  iiisi'  lilt'  i]|»'nin::  \\a>  iil^u  at.  or  near,  tlie 
ami  iiisli'ail  of  siiiail  'lowi'l  I'assinj;  into 


111! 


illli'd 

scliiiliilini'  line, 

it  the  tivary  liad  for  >oiiii'  rrasoii  oinipioi!  t  spai'C 
latiT  liad  ifoiio  on  to  tiiiiioi'  iIc\('1o|iiiil'1ii.  It  is  jii-t 
|io"il»|.'  tliat  Ihi-  woaUiu—  in  the  wall  liad  licioini'  par- 
ticuiarlv  arci'iitiialcd  clnrinL'  a  pn^'iiancy  and  that  tin' 
ovary  dnrini:  it-  ascent  with  thi'  piv-naiit  iiltMii-  had 
droppi'il  into  thf    'aNily. 

Ill   .Hiiclii-iuii.    1    vvi-li   til   lli^MiU    1)1.    Kivd    l!;n    lor   lii-   ki'i.l- 
111--    ill    I'l'irrtill^'    mil     lln'    IrOTrllc  r-    In    tllr    mlicli'-    Iiil4     •/ 

nil'    ill    till-    iiri'iiiiniti I    tlii-    \i.\\'fr.    ni.l    I    mil    i-pi'ri.illy 

ii,ili-l)li',|  In  Mr.  Max  Iti.Mlrl  :iii.l  lln'  1-i.iiii.hiI  imi  of  Art  ill 
.Mriliiilli'  of  till"  .lollll-  llo|.l^ill-  Mr.lii.ll  ^illool  for  llir  r\r,  1- 
li'iii    illii-ti  iitioii-. 


